The Future of AIDS

Nicholas Eberstadt

From Foreign Affairs, November/December 2002

Summary:  In the decades ahead, the center of the global HIV/AIDS pandemic is set to shift from Africa to Eurasia. The death toll in that region's three pivotal countries--Russia, India, and China--could be staggering. This will assuredly be a humanitarian tragedy, but it will be much more than that. The disease will alter the economic potential of the region's major states and the global balance of power. Moscow, New Delhi, and Beijing could take steps to mitigate the disaster--but so far they have not.

Nicholas Eberstadt holds the Henry Wendt Chair in Political Economy at the American Enterprise Institute and is Senior Adviser to the National Bureau of Asian Research. This essay draws on a longer study prepared with the assistance of Lisa Howie; for more detailed results see www.AEI.org/scholars/eberstadt.htm.

Eurasian states' responses to their respective HIV crises may also be circumscribed by economic considerations. For now, the most effective medical intervention for prolonging HIV patients' lives is the complex "drug cocktail" of anti-retroviral drugs. It is true that many people with HIV in the advanced industrialized West have been given a new lease on life by taking these drugs, and that this has made the disease less of a life sentence than it was before. The problem with thinking that this advance represents a solution to the developing world's HIV/AIDS problems, however, is that the cocktail is extremely costly -- typically $15,000 or more per patient per year. Even the generic versions of the drugs, a year's supply of which can be manufactured for $600, are not affordable by most countries for most of their people with AIDS. And even if they had the money, the unfortunate fact is that they would probably not spend it on this cause, because the cost of distributing the treatment (even assuming that the drugs were given away free) would often be more than the economic value to governments of the lives thus saved. The tragic truth is that until some kind of actual cure is discovered, most people with HIV/AIDS in the developing world are essentially doomed.

Despite this awful reality, there are still things states can do to at least contain the risk of contagion within their populations. Governments can competently monitor the spread of the disease and warn their citizens accordingly. They can engage in public education campaigns to apprise their people of the deadly risks they face with HIV, urging them to alter specific behaviors. They can attend to the explosion of curable sexually transmitted infections, since these have proved to be a leading indicator for HIV transmission. And they can intervene with groups at high risk of HIV to encourage lifestyles that will court fewer dangers. But governments in Eurasia are not yet doing enough of these things.

HIV in the region may be likened to a gathering tempest, and the governments in Moscow, New Delhi, and Beijing to captains of vessels in its path. The storm, already within sight and rapidly advancing, is enormously powerful and capable of untold tragedy and destruction. From the captain's deck, however, officers continue to regard the approaching squall with curious detachment, unconcerned about its implications for their ship. When they come to their senses, the tempest will be even nearer than it is now -- and they may discover that their ability to navigate out of harm's way is more limited than they would have supposed.

For the technically inclined, I assumed that 1) each epidemic got underway around 1985; 2) in each country, the median incubation period for HIV carriers between infection with HIV and the onset of AIDS is nine years; 3) life expectancy after the onset of AIDS averages two years; and 4) HIV epidemics in Russia, China, and India are all subject to the "standard heterosexual" distribution between the sexes and over age groups that has been witnessed in other low-income countries (especially those of sub-Saharan Africa). For computing demographic and epidemiological results, I selected the spectrum software package developed by the Futures Group International for the U.S. Agency for International Development.

Table 1: Cumulative New HIV Cases, 2000-2025

Mild Epidemic Intermediate Epidemic Severe Epidemic

China 32 million 70 million 100 million

India 30 million 110 million 140 million

Russia 4 million 13 million 19 million

Note: All figures in this table and the ones that follow are projections based on the model described.